Implementing an Outpatient Service in A Social
Health Insurance System in Kenya: A Capacity
Building for Effective Health Fellows’ Perspective
Kenya Health Morans
Hanoi, Vietnam
10 May, 2010
PROJECT OPTIONS
Option 1: Research question
Can capitation assure quality of healthcare
and reduce out of pocket expenditure for
the poor and vulnerable in Kenya?
Option 1 Justification
• Will offer new perspective to HF reforms. Previous reforms
have focused on resource mobilization
• Addresses targeting shortcoming in NHIF outpatient pilot
which does not cover poor and vulnerable
• Experiential approach advocated as a powerful way of
testing PPMs
• Inform the design of the planed HFT pilot
• Develop field internship sites for CBEH programme
– Field internship sites will give CBEH Fellows the practical
experience necessary to complement didactic training, while giving
the health institutions new resources to improve management
analysis.
Project Goal
• To contribute to the improvement of the
health status and quality of life of all Kenyans,
especially the poor and vulnerable groups.
Project Objectives
• Assure quality of outpatient services
• Reduce the OOP spending on OP services by
Mathare residents
Capitation Project Cost
Estimate
Target Population
% of Population that is poor
No. of Visits per person in 1 year
No. of Visits in 6 Months
Total No of Visits during Project Period
Estimated Cost per visit
Target No. of service Providers
Average Number of Clients/Day/Provider
Contribution from Insured
members/Pooled funds
Contribution for Poor/Vulnerable
Project Management Costs
Total
5,000
46%
4
2
10,000
600
5
These
11 are order
of magnitude
estimates to be
fine tuned
3,240,000
2,760,000
2,000,000
8,000,000
Assumptions
•
•
•
•
Funding and Stakeholder Support
Provider buy in.
Provider Management and Clinical Capacity
Availability of an Implementation Team
Success Criteria
• Capitation project implemented
• Providers compliance with agreed treatment
guidelines
• Increased client satisfaction with outpatient
services
• A reduction in outpatient out of pocket
spending
Project implementationChallenges
•
•
•
•
Funding
Buy-in from stakeholders
Duplication of efforts- three pilots plannedAcceptance by the potential beneficiaries
Option 2: Research question
• Can capitation assure quality of healthcare
and reduce out of pocket expenditure for the
poor and venerable Kenya?
Option 2 Project Approach
• Same as for option 1, but piggy back on
NHIF’s pilot.
• NHIF will provide funds for members
• Fellows will seek support for funding of
indigents
Option 2 Pros
• Will have benefits of option 1, but to a
limited extent
Option 2 Cons
• Stakeholder buy-in ( NHIF and funder of
indigents)
• Perceived conflict of interest with private sector
Fellows
• Logistics of changing project design to
accommodate poor and vulnerable population
• Fellows will have no control over time, scope and
quality, key tenets of project management
• There may be no results to report at evaluation
seminar in Hanoi, Vietnam
Option 3: Research Question
• What are the critical factors for the
successful implementation of capitation in
out patient services for primary health care?
Option 3 Project Approach
• Literature review of implementation of
capitation in a number of countries, both
developing and developed
• Identification and critical analysis of critical
success factors
• Project documentation
• Development of implementation manual
Option 3 Pros
• Well thought out actionable plans for
successful introduction of outpatient services
under a social health insurance system
Option 3 Cons
• Lacks experiential approach of Options 1 and 2
• Limited documented experience of capitation in
developing countries
Implementing an Outpatient Service in A Social
Health Insurance System in Kenya: A Capacity
Building for Effective Health Fellows’ Perspective
Assumption
• This paper assumes that there are enough
revenues to provide individuals with a basic
package of essential out patient services and
financial protection against catastrophic
medical expenses caused by illness and injury
in an equitable, efficient, and sustainable
manner.
Methodology
• Development of this paper was based
information obtained from :
• Literature review
• Formal and informal meetings with health
systems and health financing experts.
Benefit Package
• The benefit package important consideration in the
uptake of health services under SHI
• Benefit package must be economically feasible, and
socially acceptable
• Based on KEPH and WHO 2008 report
• Research on regional epidemiological profiles to
inform definition of benefit packages.
• Carry out study to collect expectations of a minimum
health benefit package
• Will evolve over time
Cost Management
• Costs of benefit package will determine the financial
sustainability and survival of outpatient coverage.
• Use GTZ costing tool to cost service, triangulate with
capitation rate calculator
• Carry out market survey to determine OP service delivery
costs
• Obtain win-win situation
• Control service delivery costs through use of clinical standards
and treatment protocols
• Manage administrative costs – outsourcing and process
improvement
• Aim at not exceeding 10% of throughput
Players in OP Service Delivery
• Palyers include
– Risk Pooling Agency
– Purchasing agencies
– Service Providers
– Beneficiaries
• Separation of functions; NHIF to do risk
pooling. Purchasing of OP services to be done
by appointed service managers
Capitation Service Manager
•
•
•
•
Competitive selection process
Competition to increase efficiency
Selection should be based on:
Critical skills and competencies
– Financial and accounting experience and HR capacity
– Systems- ICT, membership/claims/accounts
payable/customer service, audit, reporting
– Health Sector Experience
• Draw up contract. Adapt from existing private sector
documents.
Service Provider
• Selection criteria should be based on:
– Location/Accessibility
– Physical capacity
– HR mix
– Range of outpatient curative and Preventative services offered
– Turnaround time(and customer service)
– Quality assurance (clinical and non-clinical)
– Integrity
– Clinical Risk management
– Cost management
– Medical infrastructure
– Accounting and Record Management systems
• Apply franchising principles to develop provider systems
• Contract to manage purchaser/provider relationship
Member Recruitment
• Identification of poor- Tool adapted from
OBA/UNICEF and GOK Poverty identification tool.
• Classify poor according to serverity; government will
first pay premiums for the most poor and
progressively increase this coverage with time to
cover all those identified as being poor.
• Members should have some choice to select their
service provider
• Recruitment process can borrow a lot from voter
registration process
Member Recruitment
• Employ various strategies to disseminate information on
member registration.,this should include:
– posters at chief camp and health facilities,
– newspaper advertisement,
– brochures issued in learning centres and at the market
place.
• Based on available budget consider use of and sophistication
of the required electronic data base, biometrics automated
methods of recognizing the member recruited will be applied.
Communication (1)
• Communication will play a critical role in the success of the out patient
scheme.
• Develop communication strategy to explain SHI principles including
solidarity
• Important to build consensus in favor of social health insurance.
• Stakeholders
– Government
– Health financing stakeholders (GTZ/MOMS/MOPHS/INWENT/health financing strategy
taskforce members/NHIF)
– Development Partners
– Private sector
– The media
– Members of the general public, the beneficiaries of the out patient service
– Service providers
– Local administration
– Community health workers/social health workers
Communication Matrix (2)
Symbol
R
A
C
I
Action
“The Doer”
Function/role
The “doer” is the individual(s) who actually complete
the task. The “doer” is responsible for
action/implementation. Responsibility can be shared.
The degree of responsibility is determined by the
individual with the “A”.
“The Buck Stops The accountable person is the individual who is
Here”
ultimately answerable for the activity or decision. This
includes “yes” or “no” authority and veto power. Only
one “A” can be assigned to an action.
“In the Loop”
The consult role is individual(s) (typically subject
matter experts) to be consulted prior to a final decision
or action. This is a predetermined need for two-way
communication. Input from the designated position is
required.
“Keep in the
This is individual (s) who needs to be informed after a
Picture”
decision or action is taken. They may be required to
take action as a result of the outcome. It is a one-way
communication
Communication (5)
• Communication will happen concurrently
and/or sequentially as per the need.
• E.g. first communicate to and finalize
contracts with the service providers/facilities
before we communicate with the potential
beneficiaries asking them to present
themselves for registration
Communication (3)
• Channels to be used include:
– Above the line- this will be of limited value if anything.
Examples of this type of communication are billboards,
newspaper adverts etc
– Below the line- these are brochures, flyers and other
amphlets. These will be used especially for communicating
to the beneficiaries of the scheme.
– Public forums eg churches, ghetto radio FM etc. this will be
used depending on the target audience. It will be an
important modality since it lends credibility to the process
and promotes understanding of the scheme benefit
package.
Communication (4)
• Key Messages to be Communicated
– Purpose/benefit of insurance
– Recruitment start and finish
– Funding partners
– Benefit package
– Periodic updates on how the project is doing
– Forums for the recruitees to air their views on the
benefits
– Report:- type/frequency and templates to be
agreed
Communication (5)
• Other Issues to be considered
– Language to be used in the communications
materials
– Use of pictorials to enhance effective
communication to the target audience especially
the beneficiaries.
– Secretariat:communication tools such as
telephones, internet connection, computers etc
Quality Management
• Quality of service delivery important for the success of out
patient scheme
• Quality Management Plan will encompass
– Management and Facility Quality
• Ownership and leadership
• Facility infrastructure, plant and equipment.
• Enterprise management systems
• Regulatory and Legal Compliance
– Clinical Quality
• Clinical Standards
• Performance Management
• Client Satisfaction
Quality Management
• The Quality management will build on existing systems such
as
– Clinical standard guidelines
– Kenya Quality Model
– The National Hospital Insurance Fund (NHIF) Master Check
List for outpatient services providers
– Various private sector and non-governmental
organizations’ quality standards.
Risk Management
• Should involve
– Risk Identification;
– Risk Quantification;
• Use the Failure Mode and Effects Analysis model. Risk
Value = Impact x Probability x Detection. Where: Impact
measures the severity of the risk on the project;
Probability measures the likelihood of the problem
occurring; Detection is defined as the ability of the
project team to discern that the risk event is imminent
– Risk Response;
– Risk Monitoring and Control Assessment
• Risk management should be iterative and participatory
Risk Management Matrix
Possible Failure Effects of
Mode
Failure
Cause of
Failure
Impact
Probability Ease of
detection
Risk Value Risk Response
Plan
Other Support Systems:
Commodity Management
• The availability of medical commodities plays a critical role in
the access of health care services and enhancing the quality
of health care delivery.
• Use of public health facilities is directly related to the
availability of drugs and other medical supplies
• Focus on areas where there are the biggest opportunities for
improvement that will deliver the highest impact on the
delivery of health services.
– Selection of essential medicines and medical commodity
list
– Pooling of procurement by private sector providers
– Distribution – explore Public Private Partnerships
Other Support Systems:
Refferal System
• OP services usually offered at level 2-3, however, recruited
members may present emergency or non emergency health
situations that require interventions in health facilities under
level 4-6 for specialized care
• Benefit package to include ambulatory services
• Define refferal protocol
• Consider using PPP
• Use existing networks e.g. St. John’s
• Establish call centre to coordinate refferal service
M&E
• M&E important for evidence-based decision making. M&E should include:
– Financing options
– population covered
– benefits package
– provider engagement
– organisational structure
– Operational processes
• Monitoring should be continuous
• Need to define indicators
• Do both baseline and tracking surveys
Challenges
•
•
•
•
•
“Big brother” influence from GTZ
Reluctant “default” champion
Perceived competition
Lack of Funding
CBEH not a legal entity
– Manage fund
– Research Permits
• Time pressure- 1st and last quarter of the year a major
challenge for most participants- planning & Budgeting
• Research and writing skills
Achievements
• NHIF agreed to incorporate capitation as an alternative
PPM in addition to FFS
• Stakeholder interactions and support especially from GTZ
• Increased understanding of PPM and impact on success
of SHI
• Gained HF knowledge
• Better understanding of the health sector documents
• Improved Private Public interactions within the group:- a
better appreciation by both sides
Acknowledgements
• GTZ Kenya Health Progamme
• KfW, Kenya
• InWEnt Team
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Alice Amayo
Konrad Obermann
Norma Lange-Tagaza
Seynabou Fachinger
Svetla Loukanova
Tanja Schwering
Thorsten Körner
Ute Schwartz
• Health Financing Stakeholders
• Employers
• Families
Thank You
Asante!